The term `prescription` can be used in reference to many related activities, including the provision of prescription medicines, the prescription of medicines, devices and dressings in the NHS, and advising patients on the purchase of over-the-counter medicines and other remedies. It may also describe “informational prescriptions,” which are written information provided to patients. Prescribing involves checking that the correct dosage of the drug – including strength, administration and frequency – is prescribed, which is especially important when prescribing children. Contraindications should also be checked, including allergies, interactions with other treatments, and underlying medical conditions. Each professional regulatory body has standards to which its members must adhere. Members are accountable for their practices to these bodies and may be sanctioned by these bodies if their actions do not meet these standards. Therefore, individuals are held accountable by their respective legal bodies for their prescribing decisions. Drug prescribing is a complex, multi-layered and technically complex process that requires careful assessment of the competing risks of harm and benefit of treatment. A good prescription requires knowledge of your patient`s disease, comorbidities and concomitant treatments.
When prescribing, the doctor should know the toxicity potential of a drug, its metabolic or excretion pathway, its interactions, precautions and contraindications, as well as its legal status. Since the enactment of the UK Human Use Medicines Regulations 2012, the prescribing of medicines can be carried out by any doctor, dentist and various other suitably qualified groups who have recently been granted prescribing privileges. All groups are required to prescribe medications in their area of responsibility and area of practice, as failure to prescribe drugs safely is responsible for a significant number of reported serious medication incidents. This chapter examines prescribing law, provider liability, consent issues, non-standard prescribing, and the legal status of non-allopathic medicines. The benefits of prescribing nurses have become increasingly evident and the potential for expansion remains. For example, the NMC Standards for Pre-Registration Care Programs (NMC, 2018a) and the Standards for Prescribing Programs (NMC, 2018b) highlight the need for newly qualified nurses to be “ready to prescribe” and have better access to prescribing programs earlier in nurses` careers. In this role, prescribing nurses are expected to demonstrate competence in professional prescribing with evidence of responsibility for clinical decisions within legal, professional and professional boundaries. Prescribing physicians are expected to operate at an advanced clinical level, reflecting current practice of improving patient care and outcomes, while challenging the practice of others that may compromise patient safety (PSR, 2021).
Legal and professional liability requires prescribing physicians to provide a rationale for: What type of medication should you prescribe based on your patient`s diagnosis? How much medication should the patient receive? How often should the drug be administered? When should the medication not be prescribed? Are there any individual factors of the patient that can lead to complications when taking the drug? Should you prescribe medication to this patient? How can different government regulations affect the prescription of this drug to this patient? The difference between the use of drugs on the label and off-label also has important implications for the doctor prescribing the drugs. In the following discussion, we will focus on the field of oncology, which can be considered a special case in off-label use, since some anticancer drugs that are effective for one indication can also be used for other forms of cancer. In this context, the position paper of the European Society for Medical Oncology (ESMO) describes a number of ethical issues; For example, ESMO`s statutes call for “promoting equal access to optimal cancer care for all cancer patients”. 12 From an ethical point of view, this is a requirement of fairness in health care and safeguards to avoid unjustified disadvantage and unnecessary harm to certain groups of patients. However, the position paper suggests that due to the approval status of a particular drug, a group of patients who can be treated with an approved drug will be treated better and more homogeneously than a group in which only off-label drugs are available, regardless of the actual effectiveness of the drug in treating the particular disease entity. There are clinical practice guidelines recommending off-label use (where there is evidence of treatment efficacy), but this is perceived by ESMO as “outside existing regulatory limits, [in a sense] `against` the law…”. 12 Although this is not the case literally and off-label use is not illegal; In fact, there are significant differences from approved drugs. From the point of view of ESMO, this results in a particular responsibility of the attending physician: the kidney is responsible for the excretion of most medicines.
It is therefore important for the prescribing nurse to understand the kidney function of her patients before making a prescribing decision. A creatinine clearance result (ClCcr) helps provide information about kidney function. The test compares the level of creatinine in the urine with the level of creatinine in the blood. The currently available method for assessing kidney function and staging of chronic kidney disease is estimated glomerular filtration rate (eGFR), a mathematically derived entity based on a patient`s serum creatinine levels, age, sex, and race. This is usually calculated by the laboratory that analyzes the blood sample and reports it with the serum creatinine result. For this purpose, several recognized and well-validated formulas were used, including the CKD-PPE equations. The “normal” GFR is generally >90 ml/minute/1.73 m2. (Note the correction of body surface area “by 1.73 m2,” which is important for certain groups of patients, such as those who have undergone amputation or extreme body habits.) It is best to track locally calculated eGFR if possible, although it can be calculated with an eGFR calculator (NICE, 2021). Nurses can consult the NICE (2021) guidelines for the classification of stages of chronic kidney disease. Prescribing a drug is one of the most common healthcare interventions to treat patients. Drugs have the potential to save lives and improve quality of life, but they also have the potential to cause damage that can sometimes be catastrophic.
Therefore, prescribing medications must be rational and effective to maximize benefits and minimize harm. The best way to achieve this is to use a systematic procedure that puts the patient at the centre of the process (Fig. 2.1). The advantages of the strategy are its ability to increase oversight of practitioners who make common mistakes and the intensity of errors to take legal action. It could be introduced to expose and punish practitioners responsible for widespread negligence and other errors. The strategy could also discover charlatans who entered the profession without qualifications, under-training or quasi-practitioners. The healthcare sector needs to focus on recording medical errors and implementing legal frameworks to deal with cases at the court level and highlight the seriousness with which medical errors are handled. The strategy would improve practitioners` attention and minimize deaths and other drug reactions that harm the patient`s health.
Within the NHS, standards of practice have been developed and monitored to ensure risks are managed and controlled. This framework also evaluates staff performance and takes corrective action if necessary. NHS organisations have clinical governance requirements for their staff, including requirements for non-medical prescriptions. Box 2.1 Overview of clinical management plan requirements for supplemental prescribing Supplemental prescribing is defined as a voluntary prescribing partnership between an independent prescribing physician (physician or dentist) and a complementary prescribing physician (nurse, pharmacist, podiatrist, physiotherapist, radiologist and optometrist) in order, with the patient`s consent, to develop a clinical treatment plan. This prescribing agreement also requires that information be shared and recorded in a shared patient record. In this form of prescription, the independent prescribing physician, i.e. the doctor or, if applicable, the dentist, conducts the initial assessment of the patient, establishes the diagnosis and the initial treatment plan. Elements of this patient-specific plan that fall under the responsibility of the additional prescriber are then documented in the patient-specific clinical management plan.
The legal requirements are set out in Box 2.1. Additional prescribers may prescribe controlled drugs as well as unauthorized and off-label drugs. (Excerpt from Background Briefing. A blueprint for safer prescribing 2009 © Reprinted with permission from the British Pharmacological Society.) Box 2.4 Guidance on prescribing unauthorized and unauthorized drugs The prescribing nurse`s ability to interact effectively and the information they need from patients to make a prescribing decision are of paramount importance (Nuttall & Howard, 2020).